Timothy Hoff thinks clinicians “must finally recognize that they are indeed ‘workers’ whose ability to control their daily fates has been reduced greatly.” He worries about the continuing erosion of the doctor-patient relationship, and he wonders why the profession is so reluctant to view its members as “put-upon workers struggling to gain favorable conditions for their work within corporatized health care settings.”

We talked with Prof. Hoff about his just-published book: “Next in Line: Lowered expectations in the age of retail- and value-based health.”

]]>https://podcasts.jwatch.org/index.php/clinical-conversations-215-has-primary-care-been-amazon-ized/2017/11/06/feed/30:18:14
Timothy Hoff thinks clinicians “must finally recognize that they are indeed ‘workers’ whose ability to control their daily fates has been reduced greatly.” He worries about the continuing erosion of the doctor-patient relati[...]
Timothy Hoff thinks clinicians “must finally recognize that they are indeed ‘workers’ whose ability to control their daily fates has been reduced greatly.” He worries about the continuing erosion of the doctor-patient relationship, and he wonders why the profession is so reluctant to view its members as “put-upon workers struggling to gain favorable conditions for their work within corporatized health care settings.”
We talked with Prof. Hoff about his just-published book: “Next in Line: Lowered expectations in the age of retail- and value-based health.”
To the barricades!
“Next in Line” (link to Oxford University Press site)
https://podcasts.jwatch.org/media/JWPodcast215.mp3
NEJM Groupnonocorporate health care, labor laws, medical practice, medicine 2.0, primary care, Amazon-ization, commercialization, consumerism, doctor-patient relationship, retail, Timothy Hoff, trusthttps://podcasts.jwatch.org/index.php/clinical-conversations-215-has-primary-care-been-amazon-ized/2017/11/06/https://podcasts.jwatch.org/media/JWPodcast215.mp3Podcast 214: Drug-drug interactions and bleeding risks with NOACshttp://feedproxy.google.com/~r/ClinicalConversations/~3/s2FCMhYMYSA/
https://podcasts.jwatch.org/index.php/podcast-214-drug-drug-interactions-and-bleeding-risks-with-noacs/2017/10/10/#commentsTue, 10 Oct 2017 15:41:09 +0000https://podcasts.jwatch.org/?p=2495

The non-vitamin-K oral anticoagulants (known familiarly as NOACs or DOACs) share metabolic pathways with other drugs, which can potentiate NOACs’ anticoagulant actions dangerously. Dr. Shang-Hung Chang and his group studied Taiwan’s national health insurance database, which records data on virtually all that nation’s citizens, to measure the actual risks of some of these drug – drug interactions. Their findings were published earlier this month in JAMA.

]]>https://podcasts.jwatch.org/index.php/podcast-214-drug-drug-interactions-and-bleeding-risks-with-noacs/2017/10/10/feed/60:00:01
The non-vitamin-K oral anticoagulants (known familiarly as NOACs or DOACs) share metabolic pathways with other drugs, which can potentiate NOACs’ anticoagulant actions dangerously. Dr. Shang-Hung Chang and his group studied Taiwan’s nat[...]
The non-vitamin-K oral anticoagulants (known familiarly as NOACs or DOACs) share metabolic pathways with other drugs, which can potentiate NOACs’ anticoagulant actions dangerously. Dr. Shang-Hung Chang and his group studied Taiwan’s national health insurance database, which records data on virtually all that nation’s citizens, to measure the actual risks of some of these drug – drug interactions. Their findings were published earlier this month in JAMA.
Links:
JAMA article (abstract)
Physician’s First Watch coverage
Anticoagulants, DOACs, NOACsNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-214-drug-drug-interactions-and-bleeding-risks-with-noacs/2017/10/10/https://podcasts.jwatch.org/media/JWpodcast214.mp3Podcast 213: Continuous glucose monitoring in pregnancies with type 1 diabeteshttp://feedproxy.google.com/~r/ClinicalConversations/~3/S-giqO_tQSA/
https://podcasts.jwatch.org/index.php/podcast-213-continuous-glucose-monitoring-in-pregnancies-with-type-1-diabetes/2017/09/22/#respondFri, 22 Sep 2017 16:36:23 +0000https://podcasts.jwatch.org/?p=2492

Pregnant women with type 1 diabetes can realize more than better control with continuous glucose monitoring: their babies are less likely to be large for gestational age and less likely to spend time in neonatal ICUs. Dr. Denice Feig, who authored a recent international study in The Lancet, talks about her findings and makes recommendations for the future.

]]>https://podcasts.jwatch.org/index.php/podcast-213-continuous-glucose-monitoring-in-pregnancies-with-type-1-diabetes/2017/09/22/feed/00:11:57
Pregnant women with type 1 diabetes can realize more than better control with continuous glucose monitoring: their babies are less likely to be large for gestational age and less likely to spend time in neonatal ICUs. Dr. Denice Feig, who authored [...]
Pregnant women with type 1 diabetes can realize more than better control with continuous glucose monitoring: their babies are less likely to be large for gestational age and less likely to spend time in neonatal ICUs. Dr. Denice Feig, who authored a recent international study in The Lancet, talks about her findings and makes recommendations for the future.
Links:
Lancet study
Physician’s First Watch summary
pregnancyNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-213-continuous-glucose-monitoring-in-pregnancies-with-type-1-diabetes/2017/09/22/https://podcasts.jwatch.org/media/JWPodcast213.mp3Podcast 212: BP in CKD — Where’s the Sweet Spot?http://feedproxy.google.com/~r/ClinicalConversations/~3/nsW66Bi0JOM/
https://podcasts.jwatch.org/index.php/podcast-212-bp-in-ckd-wheres-the-sweet-spot/2017/09/14/#respondThu, 14 Sep 2017 14:16:14 +0000https://podcasts.jwatch.org/?p=2489

There was an excellent commentary accompanying a recent JAMA Internal Medicine meta-analysis: “The Ideal Blood Pressure Target for Patients with Chronic Kidney Disease — Searching for the Sweet Spot” by Csaba Kovesdy. He offers a nice perspective on the problem and kindly agreed to talk with us.

Sometimes — but not all the time — patients can be advised to stop a course of antibiotics if they feel better. Traditionally, the advice has been to complete the entire course, regardless. Why? Because it was thought that stopping early might lead to more antibiotic resistance. That’s changing now, as the WHO and the CDC advise that courses be taken as directed by (and in consultation with) the prescriber.

Prof. Martin Llewelyn and his colleagues wrote an intriguing analysis in The BMJ of the idea of stopping treatment under certain circumstances. They point out that it’s the longer duration of treatment (and thus longer exposure of commensals to antibiotics) that’s almost certainly causing most cases of resistance.

]]>0:10:46
Sometimes — but not all the time — patients can be advised to stop a course of antibiotics if they feel better. Traditionally, the advice has been to complete the entire course, regardless. Why? Because it was thought that stopping earl[...]
Sometimes — but not all the time — patients can be advised to stop a course of antibiotics if they feel better. Traditionally, the advice has been to complete the entire course, regardless. Why? Because it was thought that stopping early might lead to more antibiotic resistance. That’s changing now, as the WHO and the CDC advise that courses be taken as directed by (and in consultation with) the prescriber.
Prof. Martin Llewelyn and his colleagues wrote an intriguing analysis in The BMJ of the idea of stopping treatment under certain circumstances. They point out that it’s the longer duration of treatment (and thus longer exposure of commensals to antibiotics) that’s almost certainly causing most cases of resistance.
Links:
Article in The BMJ
NEJM Group Open Forum starting Wednesday, Aug. 23
antibiotics, InfectionNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-211-on-not-staying-the-antibiotic-course/2017/08/20/http://podcasts.jwatch.org/media/JWPodcast211.mp3Podcast 210: Jerome Kassirer — an editor looks backhttp://feedproxy.google.com/~r/ClinicalConversations/~3/oZ60S5ffj08/
Thu, 17 Aug 2017 01:06:26 +0000http://podcasts.jwatch.org/?p=2476

Dr. Jerome P. Kassirer served as editor-in-chief of the New England Journal of Medicine from 1991 to 1999.

Almost 20 years later, Kassirer looks back on his life and his time as editor in a new autobiography, titled “Unanticipated Outcomes” — and in a conversation with us.

]]>0:24:32
Dr. Jerome P. Kassirer served as editor-in-chief of the New England Journal of Medicine from 1991 to 1999.
Almost 20 years later, Kassirer looks back on his life and his time as editor in a new autobiography, titled “Unanticipated Outcom[...]
Dr. Jerome P. Kassirer served as editor-in-chief of the New England Journal of Medicine from 1991 to 1999.
Almost 20 years later, Kassirer looks back on his life and his time as editor in a new autobiography, titled “Unanticipated Outcomes” — and in a conversation with us.
Links:
Kassirer editorial on managed care.
Kassirer on the digital transformation of medicine.
publishingNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-210-jerome-kassirer-an-editor-looks-back/2017/08/16/http://podcasts.jwatch.org/media/JWPodcast210.mp3Podcast 209: “The guidelines need to be rewritten” to encourage antibiotic use after incision and drainage of small skin abscesseshttp://feedproxy.google.com/~r/ClinicalConversations/~3/r-zelbLDY9I/
Sun, 09 Jul 2017 18:26:08 +0000http://podcasts.jwatch.org/?p=2471

Henry Chambers of UCSF found a 15-percentage-point advantage in short-term cure rates for antibiotics over placebo. The guidelines don’t encourage systemic antibiotics in these circumstances, but Chambers’ group found the advantage held both in the intention-to-treat results and among those patients who were full adherent to their regimens.

Clinical Conversations comes to you through the NEJM Group.

Executive producer, Kristin Kelley.

]]>0:14:37
The senior author of a paper examining the role of systemic antibiotics after incision-and-drainage in treating small skin abscesses says the results should prompt a rewriting of current guidelines.
Henry Chambers of UCSF found a 15-percentage[...]
The senior author of a paper examining the role of systemic antibiotics after incision-and-drainage in treating small skin abscesses says the results should prompt a rewriting of current guidelines.
Henry Chambers of UCSF found a 15-percentage-point advantage in short-term cure rates for antibiotics over placebo. The guidelines don’t encourage systemic antibiotics in these circumstances, but Chambers’ group found the advantage held both in the intention-to-treat results and among those patients who were full adherent to their regimens.
Clinical Conversations comes to you through the NEJM Group.
Executive producer, Kristin Kelley.
abscesses, antibiotics, Clindamycin, TMP-SMX, UncategorizedNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-209-the-guidelines-need-to-be-rewritten/2017/07/09/http://podcasts.jwatch.org/media/JWPodcast209.mp3Podcast 208: How inequality kills — David Ansell talks with us about his new bookhttp://feedproxy.google.com/~r/ClinicalConversations/~3/8OOcuZK2w9Y/
Sun, 11 Jun 2017 03:18:41 +0000http://podcasts.jwatch.org/?p=2467

Dr. David Ansell, a professor of medicine at Rush University Medical Center in Chicago, discusses his new book, “The Death Gap: How inequality kills.”

What’s the death gap? Look at it this way: you’re getting on the Chicago Transit Authority’s Blue Line at “The Loop” in downtown, where the average life expectancy is 85 yrs. Go 7 stops south, and you’ll end up in a place whose inhabitants have a life expectancy of 69 — lower than that in Bangladesh. That’s a “death gap” of 16 years.

It’s worse in rural America. Drive from Connecticut to rural Mississippi and see some 35 years’ life expectancy evaporate.

How did the United States get here? And what are we going to do about it?

Clinical Conversations comes to you through the NEJM Group.

Executive producer, Kristin Kelley.

]]>0:15:46
Dr. David Ansell, a professor of medicine at Rush University Medical Center in Chicago, discusses his new book, “The Death Gap: How inequality kills.”
What’s the death gap? Look at it this way: you’re getting on the Chi[...]
Dr. David Ansell, a professor of medicine at Rush University Medical Center in Chicago, discusses his new book, “The Death Gap: How inequality kills.”
What’s the death gap? Look at it this way: you’re getting on the Chicago Transit Authority’s Blue Line at “The Loop” in downtown, where the average life expectancy is 85 yrs. Go 7 stops south, and you’ll end up in a place whose inhabitants have a life expectancy of 69 — lower than that in Bangladesh. That’s a “death gap” of 16 years.
It’s worse in rural America. Drive from Connecticut to rural Mississippi and see some 35 years’ life expectancy evaporate.
How did the United States get here? And what are we going to do about it?
Clinical Conversations comes to you through the NEJM Group.
Executive producer, Kristin Kelley.
NEJM GroupnonoDeath Gap, Life expectancy, Mortality rates, Public health, "Death Gap", affordable care act, American Health Care Act, Chicago, Congress, David Ansell, health care reform, inequality, Obamacare, politics, privilege, structural violence, Trumpcare, United Stateshttps://podcasts.jwatch.org/index.php/podcast-208-how-inequality-kills-david-ansell-talks-with-us-about-his-new-book/2017/06/10/http://podcasts.jwatch.org/media/JWPodcast208.mp3Podcast 207: Fecal transplants, the gut microbiome and future medical carehttp://feedproxy.google.com/~r/ClinicalConversations/~3/r5tUZsT2gek/
Fri, 12 May 2017 23:49:14 +0000http://podcasts.jwatch.org/?p=2463

I overheard this week’s guest, Zain Kassam, discussing his work at OpenBiome a few weeks ago. All those microbes in our intestines seem destined to play an important role in the future of medical care. Right now, fecal transplants are used against Clostridium difficile infection.

Dr. Kassam kindly agreed to chat with us and describe where he thinks the field of microbiome-based therapy is headed. Among the research under way, he describes one project on ulcerative colitis and another on hepatic encephalopathy in which fecal transplants have brought surprising results.

He recommended two books during our interview, and I’ve linked to their slots on Amazon’s bookshelves below:

Clinical Conversations comes to you through the NEJM Group.

Executive producer, Kristin Kelley.

]]>0:15:12
All previous editions are available at podcasts.jwatch.org.
I overheard this week’s guest, Zain Kassam, discussing his work at OpenBiome a few weeks ago. All those microbes in our intestines seem destined to play an important role in the futu[...]
All previous editions are available at podcasts.jwatch.org.
I overheard this week’s guest, Zain Kassam, discussing his work at OpenBiome a few weeks ago. All those microbes in our intestines seem destined to play an important role in the future of medical care. Right now, fecal transplants are used against Clostridium difficile infection.
Dr. Kassam kindly agreed to chat with us and describe where he thinks the field of microbiome-based therapy is headed. Among the research under way, he describes one project on ulcerative colitis and another on hepatic encephalopathy in which fecal transplants have brought surprising results.
He recommended two books during our interview, and I’ve linked to their slots on Amazon’s bookshelves below:
Missing Microbes by Martin Blaser
Let Them Eat Dirt by B. Brett Finlay and Marie-Claire Arrieta
Clinical Conversations comes to you through the NEJM Group.
Executive producer, Kristin Kelley.
antibiotics, MicrobiomeNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-207-fecal-transplants-the-gut-microbiome-and-future-medical-care/2017/05/12/http://podcasts.jwatch.org/media/JWPodcast207.mp3Podcast 206: Gluten avoidance and cardiac riskshttp://feedproxy.google.com/~r/ClinicalConversations/~3/EICbRNpNp_w/
Sun, 07 May 2017 23:34:34 +0000http://podcasts.jwatch.org/?p=2459

Have you prepared a dinner party recently and not heard the word “gluten” come up?
Using food-frequency questionnaires, researchers followed the dietary habits of two very large cohorts of clinicians for over 25 years. Their results, just published in The BMJ suggest that, unless you have celiac disease or gluten sensitivity, you’re better off not avoiding the stuff. Our conversation is with the senior author, Andrew T. Chan.

Clinical Conversations comes to you through the NEJM Group.

Executive producer, Kristin Kelley.

Next week: We visit with the chief medical officer of OpenBiome.

]]>0:12:56
All previous editions are available at podcasts.jwatch.org.
Have you prepared a dinner party recently and not heard the word “gluten” come up?
Using food-frequency questionnaires, researchers followed the dietary habits of two very larg[...]
All previous editions are available at podcasts.jwatch.org.
Have you prepared a dinner party recently and not heard the word “gluten” come up?
Using food-frequency questionnaires, researchers followed the dietary habits of two very large cohorts of clinicians for over 25 years. Their results, just published in The BMJ suggest that, unless you have celiac disease or gluten sensitivity, you’re better off not avoiding the stuff. Our conversation is with the senior author, Andrew T. Chan.
Clinical Conversations comes to you through the NEJM Group.
Executive producer, Kristin Kelley.
Next week: We visit with the chief medical officer of OpenBiome.
diet, GlutenNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-206-gluten-avoidance-and-cardiac-risks/2017/05/07/http://podcasts.jwatch.org/media/JWPodcast206.mp3Podcast 205: Listen to the patient!http://feedproxy.google.com/~r/ClinicalConversations/~3/ihC8PbzMcRE/
Fri, 13 Jan 2017 18:11:45 +0000http://podcasts.jwatch.org/?p=2455

Danielle Ofri has written a new book, “What Patients Say, What Doctors Hear,” that’s full of advice on how best to listen to your patients. She also recounts her own adventures (and misadventures) in patient communication.

The book is published by Beacon Press, which offers a free first chapter available for immediate electronic reading. Details are on Dr. Ofri’s site.

[Running time: 15 minutes]

]]>0:14:59
Danielle Ofri has written a new book, “What Patients Say, What Doctors Hear,” that’s full of advice on how best to listen to your patients. She also recounts her own adventures (and misadventures) in patient communication.
Th[...]
Danielle Ofri has written a new book, “What Patients Say, What Doctors Hear,” that’s full of advice on how best to listen to your patients. She also recounts her own adventures (and misadventures) in patient communication.
The book is published by Beacon Press, which offers a free first chapter available for immediate electronic reading. Details are on Dr. Ofri’s site.
[Running time: 15 minutes]
Diagnosis, guidelines, listening, PatientsNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-205-listen-to-the-patient/2017/01/13/http://podcasts.jwatch.org/media/JWPodcast205.mp3Podcast 204: Medical marijuana’s effect on Medicare prescriptionshttp://feedproxy.google.com/~r/ClinicalConversations/~3/1W4pgHPsKFs/
Sun, 10 Jul 2016 23:09:52 +0000http://podcasts.jwatch.org/?p=2448

[Note: a transcript of this interview will be added in a few days’ time.]

Our guest has strong indirect evidence that medical marijuana has been replacing “standard” drugs in states where it is legal. In doing so, the substitution is saving the Medicare system modest amounts of money. Their evidence, published in Health Affairs, comes from an examination of national Medicare Part D records over a 4-year span.

]]>0:15:35
[Note: a transcript of this interview will be added in a few days’ time.]
Our guest has strong indirect evidence that medical marijuana has been replacing “standard” drugs in states where it is legal. In doing so, the substit[...]
[Note: a transcript of this interview will be added in a few days’ time.]
Our guest has strong indirect evidence that medical marijuana has been replacing “standard” drugs in states where it is legal. In doing so, the substitution is saving the Medicare system modest amounts of money. Their evidence, published in Health Affairs, comes from an examination of national Medicare Part D records over a 4-year span.
Health Affairs study (free abstract)
Physician’s First Watch coverage (free)
Costs, FDA, marijuana, MedicareNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-204-medical-marijuanas-effect-on-medicare-prescriptions/2016/07/10/http://podcasts.jwatch.org/media/JWPodcast204.mp3Podcast 203: What’s wrong with guidelineshttp://feedproxy.google.com/~r/ClinicalConversations/~3/tUGVxAljogY/
https://podcasts.jwatch.org/index.php/podcast-203-whats-wrong-with-guidelines/2016/06/09/#commentsThu, 09 Jun 2016 21:33:47 +0000http://podcasts.jwatch.org/?p=2439

JOE ELIA: You’re listening to Clinical Conversations. I’m Joe Elia.
Our guest this time is Dr. Margaret McCartney a Glasgow-based general practitioner and author. She, along with three others, wrote an essay for the BMJ in mid-May entitled “Making Evidence-Based Medicine Work for Individual Patients.”

[http://www.bmj.com/content/353/bmj.i2452]

The essay points out a few things about the guidelines that come from the evidence-based approach. Among the observations is that guidelines too often discount the patient’s role in decision-making.

There are other observations, and we’re fortunate to have Dr. McCartney here to talk about them. Welcome to Clinical Conversations, Dr. McCartney.

MARGARET MCCARTNEY: Thank you for having me.

JOE ELIA: There are lots of guidelines out there, aren’t there?

MARGARET MCCARTNEY: Yes, I don’t even think I know how many guidelines there are any more. Certainly there are heaps of them, and every day I get another alert saying there’s a new guideline I should be aware of.

JOE ELIA: And so you try to make your yourself aware of them but you can’t — you can’t be aware or compliant with everything because they often are at cross-purposes, aren’t they?

MARGARET MCCARTNEY: Well they are, and sometimes guidelines themselves are in conflict with each other, and policymaking and guidelines is another area of conflict quite often.

But one of the really big problems I have as a general practitioner working under pressure – and making lots of decisions with my patients within the confines of a 10-minute consultation — very often is how to get a really good quality decision making in there.

And part of the problem is the guidelines are so long and unwieldy that the information I really want – the really basic statistical information – is often buried really deep inside. So in order for me to try and make a rational decision with my patient – the stuff that is really useful may be buried deep in there and may not even exist in the guideline at all.

And so really what we’re questioning [in the BMJ essay] is who the guidelines are being written for just now. Are they being written with the primary purpose in mind of helping people make good decisions based on their values about what they would like to do with their health? And I think just now we’ve got an awful lot information on guidelines, but not necessarily the really good information that would help me make better decisions with patients.

JOE ELIA: You point out as a paradigm the Alberta cardiovascular risk reduction guideline, which runs two pages in length – and I’m sure that you would like to see more two-page guidelines.

MARGARET MCCARTNEY: Yes, I think summaries can be really useful.

One of the classic examples is bowel-cancer screening. And so we seem to do an awful lot of fecal occult-blood testing but not very much in terms of telling people “OK, here are the potential benefits, here are the potential harms” – written in terms of, say, absolute risk in a way that we can all understand and give each other the heads-up on it. The same with statins; the same with hypertension drugs; the same with drugs to prevent osteoporosic factors.

There’s lots and lots of preventative stuff we do, and I’m really concerned that we’re not giving high-quality information to people. And instead of the doctor’s role being enabling a conversation and discussing choices, we’re kind of being corralled into being told what the correct decision is. But until we’ve asked the patient, how can we know what the correct decision is?

I think we should know from NICE [the U.K.’s National Institute for Health and Care Excellence] what the cost-effective things are to do, but when it comes down to putting someone on a medication for maybe 15, 20, 50 years – who knows? – we should be making really good decisions about that.

JOE ELIA: You mention taking a “bifocal approach” to the guidelines in your essay. And so I think you’ve explained that already — but explain the metaphor again?

MARGARET MCCARTNEY: We’re trying to do two things at once. We want really good guidelines that give us a sense of what’s happening in our population – what is good for the population, what do we think the risks and benefits are for a population – but what we’re always addressing in the consulting room are those facts for an individual person. So what we really need to know is, What are the values that that person holds? What does that person want to avoid or what risks do they want to take?

So for some people, they will do anything other than taking a tablet. For some people, they want to take every tablet, no matter how slim the chances are they will get a benefit from it. For some people, they want to use exercise to try and mitigate as many risks as possible; for other people, that’s not going to be possible for lots of very good reasons.

So it’s about trying to really shape decisions which are based on evidence which may not even be applicable to that patient. So we need to know, Is this patient typical of the folk that were in the trials that generated these guidelines? So we really need a sense of where our person fits in with what’s already known and what should be important for that decision for that individual.

And in many ways it’s not rocket science, it’s actually quite straightforward. But then we’ve got ourselves into this mechanistic state now where guidelines have to be all-seeing — all being absolutely perfect, applicable to everyone from the super specialist to the general practitioner. Whereas providers have quite different needs a lot of the time. Until we know what our patients want we really don’t know what our patients’ needs are.

JOE ELIA: You say the quality of the evidence underlying the guidelines isn’t good. Much of it is based I think you said almost 2/3 of the evidence in one cardiovascular guideline was of dubious quality and not because research was bad but because it wasn’t based on strict evidence or randomized controlled trials.

MARGARET MCCARTNEY: We’ve got loads and loads of guidelines designed to be used by general practitioners, but the bottom line is that the data which these guidelines are based on are very nonreflective of the patients that we have in the community, who very often have multiple morbidity, who may be old, may be frail. You know it staggers me that we are applying the same kind of guidelines to someone who may be 85 and on 12 different medications with a 42-year-old who is otherwise fit and well. And the risks and benefits in these situations are quite different.

I think it’s really wrong to treat everyone as a human machine that has to be put into a guideline factory and then told what they should be on and what they should take for the rest of their lives. We’re missing humanity in that situation.

JOE ELIA: I’ve been reading your book that came out about two and half years ago – “The Patient Paradox,” and the subtitle is “Why sexed-up medicine is bad for your health.” And so I’m about 10% of the way through it and I was reading the section on statins, and on your opinion about giving statins the people who have no other indications other than “Well this might lower your bad cholesterol.”

So it’s true that that there is lots of “sexed-up” medicine out there but it doesn’t necessarily translate to …

MARGARET MCCARTNEY: I agree. We have this really ridiculous situation and just now in the UK where we’re pouring so much money into new pharmaceuticals, new technology. It’s almost magical thinking that somehow we’re going to stop death, stop people dying, and make everyone perfectly well, and make everyone’s numbers (everyone’s obsessed with numbers and measuring) perfect. And that will somehow mean that we’re all virtuous citizens who will kind of live forever. And it’s just completely crazy.

We know that health inequality is a major problem. You know, if you’re poor in Glasgow you will die 20 years younger than if you live in a rich area. Therein sits the problem. And any amount of statins won’t help out.

We know there is really good evidence that says that if you are already healthy you’re most likely to comply with all preventatives in health interventions, be that screening or statins or whatever else. So if you aim all your public-health strategy on preventative medicine that requires that kind of uptake — like taking a statin, taking a blood pressure pill and taking a bowel cancer screening — the problem is that you’re directly giving more resources to the people who are already going to live the longest and you’re leaving the poorest people yet again behind. And that’s the major problem.

So the theme of “The Patient Paradox” is that we keep doing things to people who are well and have got a small chance of benefit. While the people who really should be becoming patients — who should be getting particularly mental health treatments, which is an ongoing scandal of delays and of obfuscation – they are the people who would benefit most from intervention from health care services. And yet because you almost have to advocate for yourself to get it you end up in the back of the queue again and again, and that’s the paradox I’m talking about. We’re aiming our resources at the wrong people.

This was famously described as the “inverse care law” by Julian Tudor Hart [in the Lancet in 1971], and “The Patient Paradox” is really me saying well, I think it’s really worse than that now. Because not only are we giving less care to the people who need it most, we’re actually giving ineffective and harmful care to people who need it least.

JOE ELIA: You’ve got a new book coming out in November on the U.K.’s National Health Service. Can you give us a little preview?

MARGARET MCCARTNEY: So it’s called “The State of Medicine: Keeping the Promise of the NHS.” My conflict-of-interest that I am absolutely committed to working within NHS. I think it is the best health service in the world, but it has been systemically underfunded and run on short-term political populist policies that were based on no evidence whatsoever, [the policies] have wasted resources, have put more resources to people again that don’t need it while ignoring the people that do, created more health inequalities, and it’s just become this political football.

I want to see a new era where we run our evidence-based NHS with compassion, with professionalism, with patients right in the helm working out where we best go. Having a system that is based on needs rather than wants and really reprofessionalizing where we work. I think the NHS is the best thing the world. I have many friends in America who tell me terrible stories of what happens with inequalities, and it’s a real big problem. People who are right at the bottom of almost the pecking order seem to get less and less as we move towards a more consumerist model, which is bad for everyone.

JOE ELIA: If you could ask your colleagues here in the US or there in the UK to do one thing differently next week in their clinics, what would it be?

MARGARET MCCARTNEY: Oh they could teach me! I’m very average – below average. I don’t think I should be telling anyone else what to do.

There’s one thing, though. I think it should be to have coffee together. We work in a system now where you’re tethered to a computer all the time. My worst days at work — the days when I feel most stressed and distressed — are the days where I don’t manage to have 10 minutes with my colleagues to ask for advice, to talk about what I’m doing, to get their feedback, to talk about what we did for the weekend – just that kind of communality with other people.

And it’s so easy now when we’re tethered to a desk, tethered to a computer, to be really isolated and actually quite lonely as a doctor. And you know, I need other people around me to support me and guide me and help me. That’s only my advice. I’m sure people would like to not take it if they want to! I think the problem has become that we’re atomized almost as doctors now. We’re working to protocols, looking at computers instead of looking at our patients. And our biggest resources are the staff that work at the NHS and the people that use it.

JOE ELIA: Well, Dr. Margaret McCartney, thank you so much for spending time with us today.

That was the 203rd Clinical Conversation. The others are available, free, at http://podcasts.jwatch.org. My executive producer is Kristin Kelley, and we come to you through the NEJM Group. I’m Joe Elia; thank you for listening.

]]>https://podcasts.jwatch.org/index.php/podcast-203-whats-wrong-with-guidelines/2016/06/09/feed/10:11:59
Download the TRANSCRIPTION_JWPodcast203
We talk with Dr. Margaret McCartney of Glasgow about her essay in The BMJ. She and her three co-authors titled it “Making Evidence-Based Medicine Work for Individual Patients.”
Note: We’re going to[...]
Download the TRANSCRIPTION_JWPodcast203
We talk with Dr. Margaret McCartney of Glasgow about her essay in The BMJ. She and her three co-authors titled it “Making Evidence-Based Medicine Work for Individual Patients.”
Note: We’re going to start including transcripts, and may even add transcripts to earlier podcasts. Let me know your reactions at jelia@nejm.org.
BMJ essay
Transcript of Podcast 203
Guest: Dr. Margaret McCartney
June 2016
JOE ELIA: You’re listening to Clinical Conversations. I’m Joe Elia.
Our guest this time is Dr. Margaret McCartney a Glasgow-based general practitioner and author. She, along with three others, wrote an essay for the BMJ in mid-May entitled “Making Evidence-Based Medicine Work for Individual Patients.”
[http://www.bmj.com/content/353/bmj.i2452]
The essay points out a few things about the guidelines that come from the evidence-based approach. Among the observations is that guidelines too often discount the patient’s role in decision-making.
There are other observations, and we’re fortunate to have Dr. McCartney here to talk about them. Welcome to Clinical Conversations, Dr. McCartney.
MARGARET MCCARTNEY: Thank you for having me.
JOE ELIA: There are lots of guidelines out there, aren’t there?
MARGARET MCCARTNEY: Yes, I don’t even think I know how many guidelines there are any more. Certainly there are heaps of them, and every day I get another alert saying there’s a new guideline I should be aware of.
JOE ELIA: And so you try to make your yourself aware of them but you can’t — you can’t be aware or compliant with everything because they often are at cross-purposes, aren’t they?
MARGARET MCCARTNEY: Well they are, and sometimes guidelines themselves are in conflict with each other, and policymaking and guidelines is another area of conflict quite often.
But one of the really big problems I have as a general practitioner working under pressure – and making lots of decisions with my patients within the confines of a 10-minute consultation — very often is how to get a really good quality decision making in there.
And part of the problem is the guidelines are so long and unwieldy that the information I really want – the really basic statistical information – is often buried really deep inside. So in order for me to try and make a rational decision with my patient – the stuff that is really useful may be buried deep in there and may not even exist in the guideline at all.
And so really what we’re questioning [in the BMJ essay] is who the guidelines are being written for just now. Are they being written with the primary purpose in mind of helping people make good decisions based on their values about what they would like to do with their health? And I think just now we’ve got an awful lot information on guidelines, but not necessarily the really good information that would help me make better decisions with patients.
JOE ELIA: You point out as a paradigm the Alberta cardiovascular risk reduction guideline, which runs two pages in length – and I’m sure that you would like to see more two-page guidelines.
MARGARET MCCARTNEY: Yes, I think summaries can be really useful.
One of the classic examples is bowel-cancer screening. And so we seem to do an awful lot of fecal occult-blood testing but not very much in terms of telling people “OK, here are the potential benefits, here are the potential harms” – written in terms of, say, absolute risk in a way that we can all understand and give each other the heads-up on it. The same with statins; the same with hypertension drugs; the same with drugs to prevent osteoporosic factors.
There’s lots and lots of preventative stuff we do, and I’m really concerned that we’re not giving high-quality information to people. And instead of the doctor’s role being enabling a conversation and discussing choices, we’re kind of being c[...]Audio, guidelinesNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-203-whats-wrong-with-guidelines/2016/06/09/http://podcasts.jwatch.org/media/JWPodcast203.mp3Podcast 202: Disaster Medicine — a New Editionhttp://feedproxy.google.com/~r/ClinicalConversations/~3/Pna_RX6Hs64/
Thu, 12 May 2016 19:33:41 +0000http://podcasts.jwatch.org/?p=2435

Drs. Kristi Koenig and Carl Schultz have just published a second edition of their textbook Disaster Medicine: Comprehensive principles and practices. And they do mean comprehensive.

The book runs some 750 pages, covering everything from ethics (not so different from “normal” ethics, it turns out) to managing mass gatherings (a nice guide is provided), tornadoes, volcanoes, and all the rest of the things that take societies unaware.

]]>0:22:21
Drs. Kristi Koenig and Carl Schultz have just published a second edition of their textbook Disaster Medicine: Comprehensive principles and practices. And they do mean comprehensive.
The book runs some 750 pages, covering everything from ethics[...]
Drs. Kristi Koenig and Carl Schultz have just published a second edition of their textbook Disaster Medicine: Comprehensive principles and practices. And they do mean comprehensive.
The book runs some 750 pages, covering everything from ethics (not so different from “normal” ethics, it turns out) to managing mass gatherings (a nice guide is provided), tornadoes, volcanoes, and all the rest of the things that take societies unaware.
Here’s a link to the book on Amazon.
Audio, Disasters, TextbooksNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-202-disaster-medicine-a-new-edition/2016/05/12/http://podcasts.jwatch.org/media/JWPodcast202.mp3Podcast 201: The NFL’s concussion-research flawshttp://feedproxy.google.com/~r/ClinicalConversations/~3/eTyakamc1ck/
Fri, 08 Apr 2016 15:52:37 +0000http://podcasts.jwatch.org/?p=2430

A conversation with Dr. Ira Casson (who served on the National Football League’s committee on mild traumatic brain injury and co-authored several of its studies on MTBI) reveals that it may be impossible to assess the value of its six-season study. Despite the author’s defense of the methods used to conduct the research, there’s room for skepticism, both in the light of a New York Times story reporting that over 10% of such injuries may have gone unreported and the study’s assumption that all teams reported all injuries.

We asked the League to make the studies’ first author available for this conversation, and they declined.

]]>0:17:57
A conversation with Dr. Ira Casson (who served on the National Football League’s committee on mild traumatic brain injury and co-authored several of its studies on MTBI) reveals that it may be impossible to assess the value of its six-season [...]
A conversation with Dr. Ira Casson (who served on the National Football League’s committee on mild traumatic brain injury and co-authored several of its studies on MTBI) reveals that it may be impossible to assess the value of its six-season study. Despite the author’s defense of the methods used to conduct the research, there’s room for skepticism, both in the light of a New York Times story reporting that over 10% of such injuries may have gone unreported and the study’s assumption that all teams reported all injuries.
We asked the League to make the studies’ first author available for this conversation, and they declined.
Concussion, football, MTBI, NFLNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-201-the-nfls-concussion-research-flaws/2016/04/08/http://podcasts.jwatch.org/media/JWPodcast201.mp3Podcast 200: Sorting out the results of breast biopsyhttp://feedproxy.google.com/~r/ClinicalConversations/~3/mqfdQh3HRDk/
Fri, 25 Mar 2016 23:29:34 +0000http://podcasts.jwatch.org/?p=2423

Most of the time, pathologists agree with each other about breast biopsy results — especially when the biopsy is negative or indicates invasive cancer. However, the biopsies that fall between those two extremes — that is, atypia and ductal carcinoma in situ — make for tough conversations with patients.

This week’s guest, Alexander Borowsky, has written an editorial (with Laura Esserman) about the problem, and he offers advice to clinicians about conveying diagnostic uncertainty. Their editorial also calls into question the words used to describe breast biopsy results, pointing out that a report of “ductal carcinoma” in situ has a way of making people reach for their scalpels — not always wisely.

The editorial accompanies a study in the Annals of Internal Medicine that examines precision of biopsy diagnoses.

(One aspect of the editorial we never got to discuss in the podcast was its citation of “Car Talk,” on the question how uncertainties feed into each other. That’s worth a link, given below.)

]]>0:23:20
Most of the time, pathologists agree with each other about breast biopsy results — especially when the biopsy is negative or indicates invasive cancer. However, the biopsies that fall between those two extremes — that is, atypia and duc[...]
Most of the time, pathologists agree with each other about breast biopsy results — especially when the biopsy is negative or indicates invasive cancer. However, the biopsies that fall between those two extremes — that is, atypia and ductal carcinoma in situ — make for tough conversations with patients.
This week’s guest, Alexander Borowsky, has written an editorial (with Laura Esserman) about the problem, and he offers advice to clinicians about conveying diagnostic uncertainty. Their editorial also calls into question the words used to describe breast biopsy results, pointing out that a report of “ductal carcinoma” in situ has a way of making people reach for their scalpels — not always wisely.
The editorial accompanies a study in the Annals of Internal Medicine that examines precision of biopsy diagnoses.
(One aspect of the editorial we never got to discuss in the podcast was its citation of “Car Talk,” on the question how uncertainties feed into each other. That’s worth a link, given below.)
Annals of Internal Medicine editorial (subscription required)
Annals study (free abstract)
Car Talk episode (start listening at the 17 min, 45 sec mark)
biopsy, screeningNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-200-sorting-out-the-results-of-breast-biopsy/2016/03/25/http://podcasts.jwatch.org/media/JWPodcast200.mp3Podcast 199: Rethinking what medical journals dohttp://feedproxy.google.com/~r/ClinicalConversations/~3/aeKnCDnXUYg/
https://podcasts.jwatch.org/index.php/podcast-199-rethinking-what-medical-journals-do/2016/03/15/#commentsTue, 15 Mar 2016 18:16:21 +0000http://podcasts.jwatch.org/?p=2420

There’s change in the air about science publishing, and Harlan Krumholz, the founding editor of the journal Circulation: Cardiovascular Quality and Outcomes, thinks it’s time to reimagine the whole concept of what a journal is and what it does.

He poured his ideas into an editorial, “The End of Journals,” which he published as he approached the end of his editorship. We finally caught up with him weeks later (he’s elusive) and talked about those ideas.

(As this podcast was being readied for posting, the New York Times published an account of Nobel laureate Carol Greider’s posting of work on bioRxiv. She celebrated by tweeting under #ASAPbio.)

]]>https://podcasts.jwatch.org/index.php/podcast-199-rethinking-what-medical-journals-do/2016/03/15/feed/30:24:41
There’s change in the air about science publishing, and Harlan Krumholz, the founding editor of the journal Circulation: Cardiovascular Quality and Outcomes, thinks it’s time to reimagine the whole concept of what a journal is and what [...]
There’s change in the air about science publishing, and Harlan Krumholz, the founding editor of the journal Circulation: Cardiovascular Quality and Outcomes, thinks it’s time to reimagine the whole concept of what a journal is and what it does.
He poured his ideas into an editorial, “The End of Journals,” which he published as he approached the end of his editorship. We finally caught up with him weeks later (he’s elusive) and talked about those ideas.
(As this podcast was being readied for posting, the New York Times published an account of Nobel laureate Carol Greider’s posting of work on bioRxiv. She celebrated by tweeting under #ASAPbio.)
publishingNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-199-rethinking-what-medical-journals-do/2016/03/15/http://podcasts.jwatch.org/media/JWPodcast199.mp3Podcast 198: Three laws that could reduce U.S. firearm mortalityhttp://feedproxy.google.com/~r/ClinicalConversations/~3/JeKbyrua908/
https://podcasts.jwatch.org/index.php/podcast-198-three-laws-that-could-reduce-u-s-firearm-mortality/2016/03/10/#commentsThu, 10 Mar 2016 23:30:52 +0000http://podcasts.jwatch.org/?p=2415

In the Lancet, Dr. Bindu Kalesan and her colleagues examined state gun laws associated with the lowest mortality rates and concluded that if three of those laws were implemented at the national level, rates would drop by over 90%.

]]>0:16:53
The authors of the new sepsis definitions encouraged “debate and discussion,” and an editorial in Chest was quick to provide it.
The editorialist, Dr. Steven Simpson, is worried about missing some cases if consideration of SIRS (th[...]
The authors of the new sepsis definitions encouraged “debate and discussion,” and an editorial in Chest was quick to provide it.
The editorialist, Dr. Steven Simpson, is worried about missing some cases if consideration of SIRS (the systemic inflammatory response syndrome) is tossed out of the definition.
Chest editorial (free PDF available if you scroll down that landing page)
Last week’s interview on the new defintions (free)
Infection, sepsis, SIRSNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-197-a-dissent-on-sepsis/2016/03/04/http://podcasts.jwatch.org/media/JWPodcast197.mp3Podcast 196: Sepsis redefinedhttp://feedproxy.google.com/~r/ClinicalConversations/~3/Lea3VwvjV2U/
https://podcasts.jwatch.org/index.php/podcast-196-sepsis-redefined/2016/02/27/#commentsSun, 28 Feb 2016 03:40:57 +0000http://podcasts.jwatch.org/?p=2408

We have Edward Abraham, Dean of Wake Forest School of Medicine, with us to talk about the new definitions of sepsis and septic shock. He wrote an editorial in JAMA that puts the changed definitions into perspective for clinicians. Listen in.

]]>https://podcasts.jwatch.org/index.php/podcast-196-sepsis-redefined/2016/02/27/feed/10:10:41
We have Edward Abraham, Dean of Wake Forest School of Medicine, with us to talk about the new definitions of sepsis and septic shock. He wrote an editorial in JAMA that puts the changed definitions into perspective for clinicians. Listen in.
E[...]
We have Edward Abraham, Dean of Wake Forest School of Medicine, with us to talk about the new definitions of sepsis and septic shock. He wrote an editorial in JAMA that puts the changed definitions into perspective for clinicians. Listen in.
Editorial in JAMA (free)
JAMA paper with new definitions (free)
NEJM Journal Watch coverage (free)
sepsisNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-196-sepsis-redefined/2016/02/27/http://podcasts.jwatch.org/media/JWPodcast196.mp3Podcast 195: Pioglitazone for secondary prevention?http://feedproxy.google.com/~r/ClinicalConversations/~3/JZBdKgh9Yes/
Thu, 18 Feb 2016 17:22:34 +0000http://podcasts.jwatch.org/?p=2405

Pioglitazone, long known to increase insulin sensitivity, has been “mostly relegated to use in unusual conditions such as lipodystrophies” after its drug class, the thiazolidinediones, “fell from grace” in the words of our guest.

Dr. Clay Semenkovich has just written an editorial comment on a study in the New England Journal of Medicine. That study showed a benefit from pioglitazone use in the secondary prevention of vascular events among patients with insulin resistance (but not diabetes) who’d had a recent ischemic stroke or TIA.

He discusses the implications of those findings and, given the drug’s side effects, cautions against a rush to prescribing pioglitazone without first discussing the trade-offs with patients.

]]>0:10:29
Pioglitazone, long known to increase insulin sensitivity, has been “mostly relegated to use in unusual conditions such as lipodystrophies” after its drug class, the thiazolidinediones, “fell from grace” in the words of our g[...]
Pioglitazone, long known to increase insulin sensitivity, has been “mostly relegated to use in unusual conditions such as lipodystrophies” after its drug class, the thiazolidinediones, “fell from grace” in the words of our guest.
Dr. Clay Semenkovich has just written an editorial comment on a study in the New England Journal of Medicine. That study showed a benefit from pioglitazone use in the secondary prevention of vascular events among patients with insulin resistance (but not diabetes) who’d had a recent ischemic stroke or TIA.
He discusses the implications of those findings and, given the drug’s side effects, cautions against a rush to prescribing pioglitazone without first discussing the trade-offs with patients.
NEJM editorial (free)
NEJM study (free)
Physician’s First Watch coverage (free)
Diabetes, Pioglitazone, strokeNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-195-pioglitazone-for-secondary-prevention/2016/02/18/http://podcasts.jwatch.org/media/JWPodcast195.mp3Podcast 194: Rising middle-age mortality rates are worryinghttp://feedproxy.google.com/~r/ClinicalConversations/~3/ylsUznNyt48/
Wed, 03 Feb 2016 15:11:06 +0000http://podcasts.jwatch.org/?p=2401

Ever since Anne Case and Angus Deaton published a paper in the Proceedings of the National Academy of Sciences last November there has been a spate of commentary over their major finding: mortality rates among middle-aged whites in the U.S. are rising while everyone else’s are improving.

The Commonwealth Fund has just published an “issue brief” on the topic, and we’ve got the authors — senior researcher David Squires and Fund president David Blumenthal — to talk things over with us.

]]>0:13:24
Ever since Anne Case and Angus Deaton published a paper in the Proceedings of the National Academy of Sciences last November there has been a spate of commentary over their major finding: mortality rates among middle-aged whites in the U.S. are ris[...]
Ever since Anne Case and Angus Deaton published a paper in the Proceedings of the National Academy of Sciences last November there has been a spate of commentary over their major finding: mortality rates among middle-aged whites in the U.S. are rising while everyone else’s are improving.
The Commonwealth Fund has just published an “issue brief” on the topic, and we’ve got the authors — senior researcher David Squires and Fund president David Blumenthal — to talk things over with us.
Commonwealth Fund issue brief (free)
PNAS study (free)
NEJM GroupnonoMiddle age, Mortality rates, Public health, Commonwealth Fund, David Blumenthal, David Squires, middle age, mortality rates, Policy, public healthhttps://podcasts.jwatch.org/index.php/podcast-194-rising-middle-age-mortality-rates-are-worrying/2016/02/03/http://podcasts.jwatch.org/media/JWPodcast194.mp3Podcast 193: Glioma survival lengthenedhttp://feedproxy.google.com/~r/ClinicalConversations/~3/7Sd4yLkbVOw/
Mon, 21 Dec 2015 01:32:41 +0000http://podcasts.jwatch.org/?p=2393

We usually don’t venture into oncology here, but the approach taken to glioma treatment in a JAMA paper — maintenance therapy with chemotherapy plus alternating electrical fields delivered transdermally via transducers — seems worth reporting to all clinicians. It prolonged patients’ lives significantly, which, according to an editorialist, hasn’t occurred in this disease in at least a decade.

The first-author of the manufacturer-sponsored research, Dr. Roger Stupp, explains the approach and the implications it holds for patients with this rapidly progressing tumor.

]]>0:15:28
We usually don’t venture into oncology here, but the approach taken to glioma treatment in a JAMA paper — maintenance therapy with chemotherapy plus alternating electrical fields delivered transdermally via transducers — seems wor[...]
We usually don’t venture into oncology here, but the approach taken to glioma treatment in a JAMA paper — maintenance therapy with chemotherapy plus alternating electrical fields delivered transdermally via transducers — seems worth reporting to all clinicians. It prolonged patients’ lives significantly, which, according to an editorialist, hasn’t occurred in this disease in at least a decade.
The first-author of the manufacturer-sponsored research, Dr. Roger Stupp, explains the approach and the implications it holds for patients with this rapidly progressing tumor.
Physician’s First Watch coverage (free)
JAMA paper (free)
JAMA editorial (subscription required)
Cancer, GliomaNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-193-glioma-survival-lengthened/2015/12/20/http://podcasts.jwatch.org/media/JWPodcast193.mp3Podcast 192: Are we too sweet on HbA1c testing?http://feedproxy.google.com/~r/ClinicalConversations/~3/9fUOtyWpUi4/
Thu, 10 Dec 2015 21:10:45 +0000http://podcasts.jwatch.org/?p=2388

Over half the patients with Type 2 diabetes have their HbA1c measured too frequently — i.e., at least three times a year. Why is that a bad thing? Dr. Rozalina McCoy, the lead author of a paper in The BMJ explains.

Using claims data, her group followed over 30,000 patients with stable HbA1c levels and found that only 40% had measurements taken within guideline-suggested limits — twice a year.

]]>0:15:30
Over half the patients with Type 2 diabetes have their HbA1c measured too frequently — i.e., at least three times a year. Why is that a bad thing? Dr. Rozalina McCoy, the lead author of a paper in The BMJ explains.
Using claims data, her[...]
Over half the patients with Type 2 diabetes have their HbA1c measured too frequently — i.e., at least three times a year. Why is that a bad thing? Dr. Rozalina McCoy, the lead author of a paper in The BMJ explains.
Using claims data, her group followed over 30,000 patients with stable HbA1c levels and found that only 40% had measurements taken within guideline-suggested limits — twice a year.
Links:
BMJ study on overtesting of HbA1c
Physician’s First Watch coverage of BMJ study
A November 2015 interview on treatment “deintensification” (free)
HbA1c, TestingNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-192-are-we-too-sweet-on-hba1c-testing/2015/12/10/http://podcasts.jwatch.org/media/JWPodcast192.mp3Podcast 191: The prostate screening conundrumhttp://feedproxy.google.com/~r/ClinicalConversations/~3/b6fmMhN9-Rw/
Sat, 21 Nov 2015 13:22:29 +0000http://podcasts.jwatch.org/?p=2358

[Running time: 13 minutes]

The 2008 and 2012 recommendations from the USPSTF regarding PSA-based prostate screening have been accompanied by drops in both the screening and detection rates of prostate cancer, two studies in JAMA find.

Our guest, Dr. David Penson, wrote an editorial accompanying those studies. It attempts to put these new findings into perspective and to help the patients and physicians caught in the middle of a continuing debate on the wisdom of screening.

]]>0:00:01
[Running time: 13 minutes]
The 2008 and 2012 recommendations from the USPSTF regarding PSA-based prostate screening have been accompanied by drops in both the screening and detection rates of prostate cancer, two studies in JAMA find.
Our[...]
[Running time: 13 minutes]
The 2008 and 2012 recommendations from the USPSTF regarding PSA-based prostate screening have been accompanied by drops in both the screening and detection rates of prostate cancer, two studies in JAMA find.
Our guest, Dr. David Penson, wrote an editorial accompanying those studies. It attempts to put these new findings into perspective and to help the patients and physicians caught in the middle of a continuing debate on the wisdom of screening.
Physician’s First Watch coverage of the JAMA studies and editorial (free)
screening, USPSTFNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-191-the-prostate-screening-conundrum/2015/11/21/http://podcasts.jwatch.org/media/JWPodcast191.mp3Podcast 190: Last line of antibiotic defense breachedhttp://feedproxy.google.com/~r/ClinicalConversations/~3/5-goqJ86V4Y/
Thu, 19 Nov 2015 14:05:28 +0000http://podcasts.jwatch.org/?p=2346

The Lancet Infectious Diseases has just published a worrying account from China about a dangerous antibiotic resistance factor carried on plasmids. The factor, called MCR-1, confers resistance to colistin — a last line of defense against multi-resistant Gram-negative bacilli.

The co-author of a helpful commentary in that journal, Dr. David L. Paterson of the University of Queensland in Brisbane, is our guest.

]]>0:13:47
The Lancet Infectious Diseases has just published a worrying account from China about a dangerous antibiotic resistance factor carried on plasmids. The factor, called MCR-1, confers resistance to colistin — a last line of defense against mult[...]
The Lancet Infectious Diseases has just published a worrying account from China about a dangerous antibiotic resistance factor carried on plasmids. The factor, called MCR-1, confers resistance to colistin — a last line of defense against multi-resistant Gram-negative bacilli.
The co-author of a helpful commentary in that journal, Dr. David L. Paterson of the University of Queensland in Brisbane, is our guest.
Lancet Infectious Diseases article (free abstract)
Lancet Infectious Diseases commentary (free abstract)
Physician’s First Watch coverage (free)
colistin, MCR-1NEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-190-last-line-of-antibiotic-defense-breached/2015/11/19/http://podcasts.jwatch.org/media/JWPodcast190.mp3Podcast 189: Blood Pressure Target Should Be 120, SPRINT Data Showhttp://feedproxy.google.com/~r/ClinicalConversations/~3/SnocpCqzcN4/
Mon, 09 Nov 2015 19:00:03 +0000http://podcasts.jwatch.org/?p=2334

The SPRINT study, suggesting that we aim for a systolic BP target of 120 mm Hg in high-risk hypertensive patients, has been published with much fanfare.

Dr. Paul Whelton — one of the SPRINT investigators — is our guest. He warns against setting 120 as a performance measure, observing that roughly half the patients in the aggressively treated group had levels above that.

]]>0:17:07
The SPRINT study, suggesting that we aim for a systolic BP target of 120 mm Hg in high-risk hypertensive patients, has been published with much fanfare.
Dr. Paul Whelton — one of the SPRINT investigators — is our guest. He warns ag[...]
The SPRINT study, suggesting that we aim for a systolic BP target of 120 mm Hg in high-risk hypertensive patients, has been published with much fanfare.
Dr. Paul Whelton — one of the SPRINT investigators — is our guest. He warns against setting 120 as a performance measure, observing that roughly half the patients in the aggressively treated group had levels above that.
Links:
NEJM article (free)
hypertensionNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-189-blood-pressure-target-should-be-120/2015/11/09/http://podcasts.jwatch.org/media/JWPodcast189.mp3Podcast 188: Should “deintensification” be a quality-of-care measure?http://feedproxy.google.com/~r/ClinicalConversations/~3/gmxSa3FcMak/
Sun, 01 Nov 2015 13:28:48 +0000http://podcasts.jwatch.org/?p=2327

The ACCORD trial found dangers in too-strict control of blood pressure and glucose in diabetes. Our guest has just published a study in JAMA Internal Medicine measuring the scope of the problem. Using Veterans Affairs data, his group found that “deintensification” of therapy after targets were met or exceeded was disappointingly rare.

]]>0:13:43
The ACCORD trial found dangers in too-strict control of blood pressure and glucose in diabetes. Our guest has just published a study in JAMA Internal Medicine measuring the scope of the problem. Using Veterans Affairs data, his group found that [...]
The ACCORD trial found dangers in too-strict control of blood pressure and glucose in diabetes. Our guest has just published a study in JAMA Internal Medicine measuring the scope of the problem. Using Veterans Affairs data, his group found that “deintensification” of therapy after targets were met or exceeded was disappointingly rare.
JAMA Internal Medicine study (free abstract)
Physician’s First Watch summary (free)
Deintensification, HbA1cNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-188-should-deintensification-be-a-quality-of-care-measure/2015/11/01/http://podcasts.jwatch.org/media/JWPodcast188.mp3Podcast 187: Colorectal adenomas not prevented by calcium and/or vitamin Dhttp://feedproxy.google.com/~r/ClinicalConversations/~3/cVL0rN8l7JE/
Sun, 25 Oct 2015 18:06:30 +0000http://podcasts.jwatch.org/?p=2315

We interview John Baron about his recent New England Journal of Medicine study testing the ability of calcium or vitamin D (or both) to prevent recurrences of colorectal adenomas in a population who had lesions found during colonoscopy. On follow-up after three to five years, the effects of daily calcium and/or vitamin D supplements were the same as for placebo — that is, there was no significant reduction in risk.

The results were surprising, since the same author found a protective effect for calcium in a 1999 publication in NEJM. (In that study, vitamin D wasn’t tested.)

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We interview John Baron about his recent New England Journal of Medicine study testing the ability of calcium or vitamin D (or both) to prevent recurrences of colorectal adenomas in a population who had lesions found during colonoscopy. On follow-u[...]
We interview John Baron about his recent New England Journal of Medicine study testing the ability of calcium or vitamin D (or both) to prevent recurrences of colorectal adenomas in a population who had lesions found during colonoscopy. On follow-up after three to five years, the effects of daily calcium and/or vitamin D supplements were the same as for placebo — that is, there was no significant reduction in risk.
The results were surprising, since the same author found a protective effect for calcium in a 1999 publication in NEJM. (In that study, vitamin D wasn’t tested.)
LINKS:
New England Journal of Medicine study (free abstract)
Physician’s First Watch coverage (free)
Calcium, Colonoscopy, UncategorizedNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-187-colorectal-adenomas-not-prevented-by-calcium-andor-vitamin-d/2015/10/25/http://podcasts.jwatch.org/media/JWPodcast187.mp3Podcast 186: Stop supplementing calcium!http://feedproxy.google.com/~r/ClinicalConversations/~3/vzC1gLRKDGc/
https://podcasts.jwatch.org/index.php/podcast-186-stop-supplementing-calcium/2015/10/06/#commentsTue, 06 Oct 2015 17:51:23 +0000http://podcasts.jwatch.org/?p=2302

Two analyses in the BMJ show little or no benefit from loading up older patients with calcium — indeed, the bad side effects of doing so (kidney stones and cardiovascular problems, to name two) outweigh the benefits.

Our conversation with Dr. Mark Bolland should offer reassurance to clinicians and their patients that a normal diet will provide enough of the stuff for good health.

]]>https://podcasts.jwatch.org/index.php/podcast-186-stop-supplementing-calcium/2015/10/06/feed/30:18:29
Two analyses in the BMJ show little or no benefit from loading up older patients with calcium — indeed, the bad side effects of doing so (kidney stones and cardiovascular problems, to name two) outweigh the benefits.
Our conversation wit[...]
Two analyses in the BMJ show little or no benefit from loading up older patients with calcium — indeed, the bad side effects of doing so (kidney stones and cardiovascular problems, to name two) outweigh the benefits.
Our conversation with Dr. Mark Bolland should offer reassurance to clinicians and their patients that a normal diet will provide enough of the stuff for good health.
BMJ studies (free)
Fracture risk
Bone mineral density
Physician’s First Watch coverage (free)
[Running time: 18 minutes]
CalciumNEJM Groupnonohttps://podcasts.jwatch.org/index.php/podcast-186-stop-supplementing-calcium/2015/10/06/http://podcasts.jwatch.org/media/JWPodcast186.mp3NEJM GroupnonadultStay informed of the most relevant medical developments by subscribing to Clinical Conversations (http://podcasts.jwatch.org), from NEJM Journal Watch. This podcast features a round-up of the week's top medical stories, clinically-oriented interviews and